NR-224 Fundamentals – Skills - Set 4 - Part 1

Correct Answer: Cane and left leg first, then right leg

Going down, the cane and the injured left leg move to the lower step together while the strong right leg stays above and controls the descent. That is the down with the bad half of the stair rule. Option a is incorrect because it applies the ascending rule to a descent. Sending the strong leg down first strands the injured ankle on the upper step, where it must then lower the entire body weight by itself. Option b is incorrect because hopping both feet onto one step at once removes every point of support at the same instant. Stairs are taken one leg at a time, with the cane always in contact with a surface. Option d is incorrect because the cane and the weak leg are separated. They travel as a pair in both directions on stairs, and moving the cane alone leaves a gap where the client stands on the fractured ankle.

Correct Answer: Tilt the entire bed into reverse Trendelenburg

Reverse Trendelenburg tilts the whole bed head up while the body stays in one straight plane, so the head is elevated without bending at the hips. It also reduces reflux and promotes gastric emptying. Option b is incorrect because a Fowler position articulates the bed at the hips, flexing the spine the surgeon wants kept straight. The elevation would be achieved at the cost of the ordered spinal precaution. Option c is incorrect because thirty to forty five degrees still bends the bed at the hip joint, only less sharply. Halving the angle does not remove the trunk flexion that the surgical order prohibits. Option d is incorrect because head down tilt raises intracranial and intraocular pressure, pushes abdominal contents against the diaphragm, and worsens reflux. It is used for central line insertion, not for a client who needs elevation.

Correct Answer: Lowering the bed and positioning the call light

A bed left low with brakes locked shortens any fall, and a call light in reach removes the reason clients get up alone. Both are universal fall precautions performed at the end of every encounter. Option a is incorrect because a dark room removes the lit path an older adult needs at night. Dark adaptation slows with age, and a night light along the route to the bathroom prevents an entire class of falls. Option b is incorrect because working height is for the nurse, not the client. The bed is raised to protect the nurse's back during care and must be returned to its lowest position before anyone walks away. Option d is incorrect because a closed door reduces noise but also removes the staff's line of sight to a client who may attempt to stand alone. Comfort measures never substitute for the basic room safety check.

Correct Answer: Encourage generous fluids and weight bearing activity

The calcium comes out of unloaded bone, so restoring weight bearing switches off the resorption that supplies it. Generous fluid dilutes the urine and keeps it flowing, which washes crystals out before they can grow. Option a is incorrect because the calcium in this client's urine came from the skeleton, not from meals. Severe dietary restriction also frees oxalate in the gut for absorption, which raises the risk of oxalate stones. Option b is incorrect because concentrated urine brings solutes closer to saturation and is one of the commonest causes of stone disease. Low urine volume also lets crystals sit long enough to aggregate. Option c is incorrect because more bed rest deepens the very bone loss that is releasing the calcium. Protein restriction belongs to selected renal and hepatic conditions and has no role in this adolescent's care.

Correct Answer: A tested suction setup and oxygen supply

Seizure precautions require suction that has been set up and tested, along with oxygen and a bag-valve mask, so the airway can be cleared and supported once the convulsive movements stop. Option a is incorrect because forcing any object between the teeth breaks them, lacerates the mouth and can obstruct the airway. A person having a seizure cannot swallow the tongue, so no bite device is needed. Option b is incorrect because restraints are never applied to a convulsing client. Holding the limbs down produces fractures, dislocations and soft tissue tearing, and it does nothing to shorten the seizure itself. Option d is incorrect because oral temperature routes are avoided entirely in clients on seizure precautions. Tympanic, temporal or axillary measurement carries no risk of a broken thermometer or a bitten hand during an event.

Correct Answer: Assess for pain, elimination needs and hypoxia

Agitation and pulling at tubes are communication. Pain, a full bladder, low oxygen saturation, hypoglycemia and delirium all produce this behavior, and treating the cause often ends it without any restrictive device. Option a is incorrect because four raised rails to keep a client in bed meet the definition of a restraint and require an order. A disoriented client also climbs over rails and falls from a greater height. Option b is incorrect because an order may be obtained only after less restrictive measures have been tried and documented as ineffective. Skipping that step leaves the record unable to show the legal condition for restraint was met. Option c is incorrect because a secured mitten is itself a restraint, so applying it before any alternative reverses the required order. Even an unsecured mitten does nothing about the discomfort driving the client's hands toward the tube.

Correct Answer: Applying non-skid footwear before the client ambulates

Applying footwear is a standard, unchanging task with a predictable outcome, so it falls within the assistive personnel role. The nurse still verifies that the shoes fit and that the client stands safely afterward. Option b is incorrect because fall risk screening is an assessment, and assessment stays with the registered nurse. Assistive personnel may report what they observe, but scoring a tool and turning that score into a plan requires nursing judgment. Option c is incorrect because interpretation of any vital sign belongs to the nurse. Unlicensed staff may take the lying and standing readings, yet recognizing a significant postural drop and acting on it exceeds their scope. Option d is incorrect because side rail use is an individualized clinical decision weighing entrapment and climb-over risk against benefit. Raising all four to keep a client in bed creates a restraint, which no unlicensed worker may authorize.

Correct Answer: I will raise four rails only when an order exists.

Four raised rails that keep a client from voluntarily leaving the bed meet the definition of a restraint and require an order plus everything that accompanies one. Recognizing that boundary is what the teaching aimed at. Option a is incorrect because rails do not stop a determined client, who climbs over and falls from a greater height, often headfirst. Restraint by rail also raises entrapment risk and increases injury severity rather than reducing it. Option b is incorrect because one or two raised rails help a client roll, reposition and locate the edge of the bed. Removing that support entirely takes away an assistive device and creates a hazard of its own. Option d is incorrect because a single setting applied to everyone ignores the individual weighing of benefit against entrapment and climb-over risk that each client requires. Split rails, in particular, are unsafe for a client who moves unpredictably.

Correct Answer: Roll it inward into the linen hamper

Soiled linen is rolled with the contaminated surface innermost and placed straight into the hamper brought to the bedside. That contains the organisms, keeps them off the nurse's uniform, and stops them being carried to the next client. Option a is incorrect because shaking linen throws skin scales, dust and microorganisms into the air. Everything in the room, including the client's face and the clean linen waiting on the chair, is contaminated by that single motion. Option b is incorrect because the overbed table is treated as a clean surface for meal trays and supplies. Putting anything soiled on it, even for a moment, means the surface has to be disinfected before food goes there. Option c is incorrect because the floor is the most heavily contaminated surface in the room. Linen that touches it must be discarded or relaundered, and staff then track those organisms out into the corridor on their shoes.

Correct Answer: Place a small pillow under the abdomen

A small pillow placed under the abdomen below the diaphragm reduces the exaggerated lumbar curve that prone lying creates, and it relieves pressure on the breasts. The feet hang over the mattress edge. Option b is incorrect because a bulky pillow under the head forces the already rotated neck into flexion. Prone positioning calls for a small flat pillow or none at all under the head. Option c is incorrect because pillows between the knees belong to side lying, where they keep bony prominences apart. In prone the legs are extended, and a knee pillow would defeat the extension being sought. Option d is incorrect because trochanter rolls hold the femur neutral in a supine client whose hips roll outward. Face down, the hips cannot externally rotate, so the rolls solve a problem that is not present.

Correct Answer: Perform a digital examination of the rectum

Liquid stool seeping around a hard obstructing mass is overflow from an impaction, not true diarrhea. A digital rectal examination confirms it, and it is the assessment that must precede any treatment. Option a is incorrect because slowing the bowel further hardens the mass already blocking the rectum. The drug treats a condition this client does not have and makes the real problem considerably worse. Option b is incorrect because waiting overnight allows distension, vomiting and confusion to develop while the obstruction stays in place. Fluids are part of prevention, but they cannot move a mass that is already impacted. Option d is incorrect because restricting the diet to clear liquids removes the bulk that stool needs. It is a response to infectious diarrhea, and it leaves the hardened mass sitting in the rectum untouched.

Correct Answer: Reposition the client off the reddened area

Nonblanchable redness means the pressure has already exceeded what the tissue tolerates. Removing the load is the only action that treats the cause, so the client is turned and kept off that site. Option b is incorrect because rubbing already damaged capillaries drives further injury into tissue that is short of blood. The practice was once taught and has been abandoned for exactly that reason. Option c is incorrect because heat raises the metabolic demand of tissue whose blood supply is already compromised. Warming a pressure area increases the oxygen the cells need without delivering any more of it. Option d is incorrect because intact skin does not need a dressing, and gauze adds a layer under the sacrum. Covering the site hides it from view while the pressure that caused it continues.

Correct Answer: Structure the day with activity and offer daily choices

Withdrawal and a reversed sleep pattern follow the loss of activity, structure and control. Filling the day with activity allowed by the current orders, and returning real choices, restores the daytime stimulus and the sense of control removed. Option a is incorrect because a sedative treats the symptom while the cause, a day with no activity in it, continues unchanged. Night medication also deepens daytime drowsiness and raises the risk of falls and delirium. Option b is incorrect because fewer visitors removes the last of this client's social contact. Isolation is already driving the withdrawal, and reducing human interaction pushes the mood and the day night cycle further apart. Option c is incorrect because unrestricted daytime napping is what keeps the client awake at night. Sleep improves when daylight hours are filled with activity, orientation cues and meals at consistent times.

Correct Answer: The provider responsible for the client's care

The provider comes first because new orders depend on it: imaging, neurological checks at set intervals, consults or medication holds. The charge nurse or supervisor and then the family follow, per facility policy and the client's wishes. Option a is incorrect because risk management learns of the event through the occurrence report, which is completed after direct care is delivered. Administrative routing is a separate track from the clinical notification the client needs now. Option c is incorrect because family notification occurs after the provider has been informed and follows facility policy and the client's own wishes. Calling the family first delays the orders that determine monitoring and imaging. Option d is incorrect because the supervisor is notified, but in second position. That call informs staffing and unit oversight; it produces no prescriptions for imaging, neurological checks or activity limits, which is what this client requires immediately.

Correct Answer: Jerking began in the right arm then generalized

Objective description of where the movement started and how it spread is the diagnostic data only the observer can supply. Vague summaries and speculation about cause cannot be reconstructed by anyone later. Option a is incorrect because it records a category rather than an observation. Every seizure note says a seizure occurred; what the team needs is the onset, the sequence of movement, and the duration. Option b is incorrect because the phrase for a while gives no duration, and duration is what separates a self-limited seizure from status epilepticus. Tolerated it well is an opinion, not an assessment finding. Option d is incorrect because a cause the nurse did not witness has no place in the entry. Speculation about triggers is a conclusion, and conclusions in a chart become admissions.

Correct Answer: The client rises by pulling on the walker

Pulling on the walker tips the frame toward the client and drags them forward onto it. The client must push up from the chair arms or mattress, stand, and only then reach for the walker one hand at a time. Option a is incorrect because standing inside the frame is exactly the taught position. A client who walks behind the walker turns it into a lever that pulls the body forward onto the toes, which is the opposite problem. Option c is incorrect because pushing off the armrests is the correct way to rise. Force comes from the client's own legs and arms against a stable chair, and the walker is grasped only after the client is upright. Option d is incorrect because inspecting the tips is a teaching point the client has clearly absorbed. Worn or missing rubber tips let the walker skid on smooth flooring, so checking them before every use prevents a fall.

Correct Answer: Remove the client from the room

RACE places rescue first. Anyone in immediate danger is removed before the alarm is pulled, before doors are closed and long before an extinguisher is reached, because people cannot wait for those steps. Option b is incorrect because the alarm is the second step of RACE, not the first. Activating it is essential and follows immediately, but a client lying beside burning linen cannot wait for that call. Option c is incorrect because confining the fire is the third RACE step. Closing the door of a room that still holds a client traps that person with the smoke rather than protecting them. Option d is incorrect because extinguishing comes last, and the nozzle is aimed at the base of the fire rather than the flames. Fighting a fire is attempted only when it is small and the exit is behind the nurse.

Correct Answer: Slide the client down one extended leg

A falling adult cannot be held up safely. Pulling the client close, extending one leg and letting the body slide down it controls the descent, protects the head, and keeps the nurse's back out of injury. Option a is incorrect because traction on the arms and axillae can dislocate a shoulder, and a flaccid hemiplegic shoulder subluxes with very little force. Control of a falling client comes from the gait belt at the waist. Option b is incorrect because releasing a collapsing client lets the head strike the floor unprotected. Help is summoned by shouting or the call system while the nurse stays in physical contact throughout the descent. Option c is incorrect because propping dead weight against a wall demands that the nurse absorb the whole load through a twisted spine. Back injury is the usual result, and the client still ends up on the floor.

Correct Answer: Advance the walker, then the weak leg, then the strong

The frame moves first, about six to eight inches, so two stable points of contact remain while the client steps. The weaker leg then enters the frame, and the stronger leg follows to level with or just past it. Option b is incorrect because stepping before the walker moves leaves the frame trailing behind the client. Weight lands on the weak leg with no device to share the load at the moment support is needed most. Option c is incorrect because it reverses both parts of the sequence at once. On level ground the strong leg has no reason to lead, and a walker still behind the client offers nothing to lean into. Option d is incorrect because the legs are swapped. Sending the strong leg in first makes the weak leg carry the body alone as it catches up, which defeats the pairing of the frame with the affected side.

Correct Answer: A geri-chair tray the client cannot release

A restraint is any device that reduces the client's ability to move freely, and the test is whether the client can remove it. A fixed tray prevents the client from rising, so it qualifies. Option a is incorrect because an arm board immobilizes a limb for the delivery of treatment, which regulation treats as standard medical immobilization. Its purpose is protecting the infusion site, not limiting where the client may go. Option c is incorrect because a collar is prescribed to treat an injury to the spine rather than to control behavior. Casts, traction and postoperative immobilizers sit in the same category and require no restraint order. Option d is incorrect because the functional test turns on removability. Once the client can slip the mitten off without help, freedom of movement remains intact; the identical mitten secured at the wrist would become a restraint.